A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device.
Which of the following actions by the nurse requires intervention by the charge nurse?
The nurse asks the client to demonstrate dose delivery.
The nurse administers a PCA dose for the client.
The nurse reassures the client that the PCA device will not cause an overdose.
The nurse monitors the client for oversedation.
The Correct Answer is B
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
To solve this problem, we first need to convert the client’s weight from pounds to kilograms. Then, we can calculate the total amount of amikacin needed. Finally, we can find out how many milliliters of amikacin injection the nurse should administer.
- Convert the client’s weight to kilograms: Given that 1 kg = 2.2 lbs, we can calculate the client’s weight in kilograms as follows:
Weightinkg=WeightinlbsConversionfactor=110lbs2.2lbs/kg≈50kgWeightinkg=ConversionfactorWeightinlbs=2.2lbs/kg110lbs≈50kg
- Calculate the total amount of amikacin needed: The doctor ordered 5 mg of amikacin per kg of body weight, so the total amount of amikacin needed is:
Totalamikacin=Doseperkg×Weightinkg=5mg/kg×50kg=250mgTotalamikacin=Doseperkg×Weightinkg=5mg/kg×50kg=250mg
- Find out how many milliliters of amikacin injection the nurse should administer: Given that the available amikacin injection is 250 mg/mL, we can calculate the volume of injection needed as follows:
Volumeofinjection=TotalamikacinConcentrationofinjection=250mg250mg/mL=1mLVolumeofinjection=ConcentrationofinjectionTotalamikacin=250mg/mL250mg=1mL
So, the nurse should administer 1 mL of amikacin injection.
Correct Answer is B
Explanation
Choice A rationale:
Hypernatremia (high sodium levels) is not a common side effect of spironolactone. Spironolactone is a potassium-sparing diuretic and does not typically affect sodium levels.
Choice B rationale:
Hyperkalemia (high potassium levels) is a potential adverse effect of spironolactone. As a potassium-sparing diuretic, spironolactone can cause an increase in serum potassium levels.
Choice C rationale:
Hypophosphatemia (low phosphate levels) is not typically associated with spironolactone use.
Choice D rationale:
Hypocalcemia (low calcium levels) is also not a common side effect of spironolactone.
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